Cardiac Imaging Questionnaire CarePlanner/iEX (78451, 78452, 78453, 78454)

Transcription

1 Cardiac Imaging Questionnaire CarePlanner/iEX (78451, 78452, 78453, 78454) 1. DO NOT SUBMIT IF PT is eligible for: Take Charge/FPO, Managed Care (MCD), Detox only, if PT has unmet Spend-down, is being evaluated for SSI, is on Medicaid but, another payer is prime, including Medicare, is receiving services in the inpatient setting or the ED. 2. Have you confirmed the Medicaid client s eligibility for the planned date of service of this advanced imaging procedure? Yes = Go to #3 No = STOP. Need to confirm eligibility before submitting 3. Is the client s primary medical coverage under ONE of these Medicaid Fee-For-Service eligibility programs: CNP or LCP-MNP, ERSO (Emergency Related Services Program for NonCitizens), GA? Yes = If ERSO go to #4, others go to #5 No = Do NOT proceed to submit 4. If client has ERSO (Emergency Related Services Program for NonCitizens) coverage, is this advanced imaging to treat cancer? Yes = Go to #5 No = Call Medical Assistance Customer Service Center (MACSC) at Is the client on hospice and is this advanced imaging related to the hospice diagnosis? Yes = STOP. PA not required by Medicaid. Paid for under hospice benefit. No = Go to #6 6. (M) Cardiac imaging indication, select ONE: High CAD risk (see 7 9) ECG abnormalities (10 14) CAD positive stress test (see 15 & 16) Myocardial ischemia (see 17) Structural heart disease (see 18 23) Risk stratification (see 24) Presyncope/syncope (see 25-31) Nonsustained V tach (see 32-38) LV systolic dysfunction (see 39 & 40) New onset HF (see 41) 7. HIGH CAD RISK, select ONE Chest pain by Hx & CAD risk factors (see 8) Risk factors for CAD (see 9) 8. Chest pain by Hx & CAD, select TWO: Cardiac Imaging Questionnaire updated 10/21/2011 1

2 9. Risk factors for CAD, select THREE: 10. ECG ABNORMALITIES/DRUG EFFECT WITH CAD RISK, select ALL: ECG abnormalities/drug effect (see 11) CAD risk (see 12) 11. ECG abnormalities/drug effect, select ONE: ST segment depression Patient on digoxin 12. CAD risk, select ONE: Chest pain by Hx & CAD risk factors (see 13) Risk factors for CAD (see 14) 13. Chest pain by Hx & CAD, select ONE: 14. Risk factors for CAD, select TWO: 15. CAD BY PRIOR POSITIVE STRESS TEST/CAD event, select ONE: Periodic assessment for ischemia progression Progression of anginal class Prior to discharge after MI hospitalization 6 wks post MI Post revascularization & need to stratify rehabilitation candidate Angina/anginal equivalent (see 16) 16. Angina/anginal equivalent, select ONE: New symptoms Hx of revascularization Cardiac Imaging Questionnaire updated 10/21/2011 2

3 17. ASSESS FOR MYOCDIAL ISCHEMIA WITH CULPRIT VESSEL, select ALL: Stenosis > 50% by angiogram Culprit lesion amenable to PCI 18. STRUCTURAL HET DISEASE (SHD) WITH CAD RISK, select ALL: CAD risk (see 19) SHD by TTE/TEE (see 22) 19. CAD risk, select ONE: Chest pain by Hx & CAD risk factors (see 20) Risk factors for CAD (see 21) 20. Chest pain by Hx & CAD, select ONE: 21. Risk factors for CAD, select TWO: 22. SHD by TTE/TEE, select ONE: Valvular heart disease (see 23) 23. Valvular heart disease, select ONE: AS >/= 1.0 cm 2 MVP 24. RISK STRATIFICATION FOR MAJOR SURGERY, select ONE: Canadian Class I/II/III angina NYHA Class I/II/III HF Renal insufficiency Severe valvular disease Cerebrovascular disease by Hx Cardiac Imaging Questionnaire updated 10/21/2011 3

4 25. PRESYNCOPE/SYNCOPE BY Hx, select ONE: New presyncope/syncope with SHD/CAD (see 26) New presyncope/syncope with CAD risk (see 29) New exercise-induced presyncope/syncope 26. New syncope/syncope with SHD/CAD, select ONE: SHD by TTE/TEE (see 27) 27. SHD by TTE/TEE, select ONE: Valvular heart disease (see 28) 28. Valvular heart disease, select ONE: AS >/= 1.0 cm 29. New presyncope/syncope with CAD risk, select ONE: Chest pain by Hx & CAD risk factors (see 30) Risk factors for CAD (see 31) 30. Chest pain by Hx & CAD, select ONE: 31. Risk factors for CAD, select TWO: 32. NONSUSTAINED (</= 30 SECS) V TACH BY AMBULATORY ELECTROCDIOGRAPHY/ECG/EP TESTING, select ONE: Presyncope by Hx (see 33) Syncope by Hx and CAD risk (see 36) 33. Presyncope by Hx, select ONE: SHD by TTE (see 34) Cardiac Imaging Questionnaire updated 10/21/2011 4

5 34. SHD by TTE, select ONE: Valvular heart disease (see 35) 35. Valvular heart disease, select ONE: AS >/= 1.0 cm 2 MVP 36. Syncope by Hx and CAD risk, select ONE: Chest pain by Hx & CAD risk factors (see 37) Risk factors for CAD (see 38) 37. Chest pain by Hx & CAD, select ONE: 38. Risk factors for CAD, select TWO: 39. NEWLY DISCOVERED LV SYSTOLIC DYSFUNCTION, select ALL: (see 40) No valvular heart disease No congenital heart disease 40., select ONE: By TTE By RVG 41. New onset HF, select ALL: By PE By CXR Cardiac Imaging Questionnaire updated 10/21/2011 5